The Dilemma of Early Intervention:
Some Problems in Mental Health
Screening and Labeling

Grace E. Jackson
Rapid City Regional Hospital
Rapid City, SD

Abstract

Motivated in part by a desire to identify and manage individuals considered to be at risk for serious mental disorders, early intervention programs are becoming increasingly accepted by the medical community, increasingly supported by the pharmaceutical indusŽtry, and increasingly unchallenged by the public. This article examines Some of the conŽceptual and practical difficulties associated with early, or preventive, mental health care. Examples are drawn from contemporary research as well as historical commentaries in the fields of industrial psychology, sociology, and education. The tone of the discussion is cauŽtionary, but the goal is to encourage mental health professionals and consumers to conŽsider the potential harmfulness of early intervention strategies before these programs are uncriticaily copied, expanded, or renewed.

CONCLUSION

Serious dilemmas are engendered by early intervention programs within the field of menŽtal health. The contemporary example of pre psychotic treatment programs has been given in order to illustrate a variety of methodological and logical flaws associated with premature screening and preventive drug treatment:

Specificity. Problems with specificity arise from the use of screening instruments that incorrectly identify healthy individuals as abnormal. In many investigations, the use of ambiguous features to select patients (or pre patients) has led to inappropriate labeling and treatment.

Validity. Due to the complex or vague nature of symptoms used to define categories of mental disease, it is frequently impossible for health professionals to agree upon the presŽence of pathology, the onset or resolution of illness, or the advisability or effectiveness of particular interventions.

Amplification. The emerging and expanding use of "sub-threshold" or "pre-syndromal" symptoms to identify individuals at risk for specific disorders appears to amplify the prognostic implications of self limiting or even normal mental states by identifying them as precursors to severe disease.

Kindling. By suggesting that unmedicated symptoms inevitably progress to serious and specific disease, researchers ignore that many individuals fail to develop the conditions which the kindling model predicts. Furthermore, there is little evidence to substantiate the claim that the best method of disease prevention ties in the early administration of treatments that would otherwise be reserved for the actual disease. The fallacious reaŽsoning here would recommend that bone fractures be prevented by early casting, breast cancer by preventive mastectomy, and diabetes, by preventive use of insulin.

Regardless of the seemingly benevolent intentions that inspire them, all interventions with diagnostic labels give rise to potentially adverse consequences, such as special attenŽtion (the Hawthorne Effect), self fulfilling prophecy (the Pygmalion Effect), and stigmaŽtization. The Hawthorne Effect suggests that it is impossible to arrange an allegedly "objective" study of human phenomena without the process itself contributing to the exisŽtence of significant and unplanned variables. The Pygmalion Effect suggests that individŽuals fulfill others' (positive or negative) conscious and unconscious expectations. Taken together, the Hawthorne and Pygmalion Effects remind us that the true potential of indiŽviduals might have far less to do with innate capacities than with the social forces and quality of relationships to which those individuals are exposed. Finally, the stigma associŽated with the pronouncement of a specific disorder can be devastating, due to ensuing restrictions in education and employment opportunities, disruption in critical relationŽships, and, most important, destruction of self confidence and self esteem.

In an era of loosening sensibilities about the classification of illness and the idealization of potentially very toxic means of responding to illness or distress, the words of C. S. Lewis were never more pertinent: "Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive" (1970, p, 292).